New Membership Application
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OBGC MEMBERSHIP FORM To Be Completed By Boys & Girls Club Staff: Ogdensburg Boys & Girls Club Received By: ______610 Patterson Street, P.O. Box 555 Fee Paid: ______Ogdensburg, NY 13669 Date Received: ______(315) 393-1241 (Phone) / (315) 393-1246 (Fax) Membership Status: __Yearly__ Receipt #: ______
(1)Member’s First Name: ______Middle: ______Last: ______
Home Address: ______City: ______State: ______Zip Code: ______
Date of Birth: ____/_____/_____ Age: ______Sex: Male Female (Please Circle One)
Home Phone #: (____)______E-Mail Address: ______
School: ______Grade Last Year: ______Grade This Year: ______Ethnicity: ______
*I give the Ogdensburg Boys & Girls Club permission to obtain information from my child’s school regarding report cards, attendance and standardized testing. *Parent/Guardian Signature: ______
Any Medical Problems and/or Disabilities we should be aware of: (if yes, please describe) ______
Father’s Name/Guardian: ______Work Telephone: (_____)______Ext.: ______
Place of Employment: ______Mobile Phone #: (_____)______
Mother’s Name/Guardian: ______Work Telephone: (_____)______Ext.: ______
Place of Employment: ______Mobile Phone #: (_____)______
My Child Does: ______Does Not: ______Have permission to walk home without a parent or guardian. (Please Check One) (Circle all that apply) 01 – TANF 02 – Food Stamps 03 – General Assistance 04 – SSDI 05 – SSI 06 – Veterans Compensation 07 – Day Care Voucher 08 – School Lunch 09 – Medicaid 10 – Can Swim In An EMERGENCY, Please Contact:
Emergency Contact: ______Phone #: (____)______
Authorized Person To Pick Up Your Child(ren) Other than Parent(s):
Name: ______Phone #: (____)______Relationship: ______Membership Fee- $6, Family Membership- $15 Please contact club staff if you are requesting a scholarship. I have read the OBGC Members Handbook and understand the rules of the Ogdensburg Boys & Girls Club and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and agree that the Ogdensburg Boys & Girls Club will not be responsible for any accident to the boy/girl while on the Ogdensburg Boys & Girls Club premises or while engaged in any of its activities away from the Ogdensburg Boys & Girls Club. I give my consent for photographs or videos in which my son/daughter may appear participating in club activities, to be used in any way the Ogdensburg Boys & Girls Club may care to use them. I also agree to allow my child to participate in Youth Surveys conducted by the Ogdensburg Boys and Girls Club. All club members will be encouraged to live healthy by eating right and participating in 20% of their time at the club in physical activity & exercise. Members of the OBGC will be expected to use any technological devices including OBGC property (computers) and personal property (cell phones) in a responsible and appropriate manner. Any misuse will result losing privileges of future use. Members are expected to participate in academic programs at the club when scheduled.
______(Parents Signature) (Date)
TURN OVER FOR ADDITIONAL CHILDREN (2) Member’s First Name: ______Middle: ______Last: ______
Home Address: ______City: ______State: ______Zip Code: ______
Date of Birth: ____/_____/_____ Age: ______Sex: Male Female (Please Circle One)
Home Phone #: (____)______E-Mail Address: ______
School: ______Grade Last Year: ______Grade This Year: ______Ethnicity______
(3)Member’s First Name: ______Middle: ______Last: ______
Home Address: ______City: ______State: ______Zip Code: ______
Date of Birth: ____/_____/_____ Age: ______Sex: Male Female (Please Circle One)
Home Phone #: (____)______E-Mail Address: ______
School: ______Grade Last Year: ______Grade This Year: ______Ethnicity:______
(4)Member’s First Name: ______Middle: ______Last: ______
Home Address: ______City: ______State: ______Zip Code: ______
Date of Birth: ____/_____/_____ Age: ______Sex: Male Female (Please Circle One)
Home Phone #: (____)______E-Mail Address: ______
School: ______Grade Last Year: ______Grade This Year: ______Ethnicity:______